Analysis Handling and Trim Having left the St. Lambert lock, the pilot noted that the vessel was difficult to steer, but not to the extent of asking the master to correct the trim by the head. The SUNNY BLOSSOM, on leaving No. 4 lock at Beauharnois had a trim by the head of 23 cm. In general, vessels with a slight trim by the head do not experience an appreciable falling off in their steering characteristics. As trim by the head increases, the vessel's steering characteristics are adversely affected. A trim by the head of 23 cm is not, in principle, unacceptable for a vessel such as the SUNNY BLOSSOM, with a length of 161 m. That this was the case is borne out by the vessel's successful passage, at this trim, of the South Shore and Beauharnois Canals, where good steering is of primary importance. The fact that the pilots continued on, before and after knowing the true trim, is tacit evidence that this trim is not unacceptable, at least not to the pilots. After a comment on this negative trim by lock personnel at Beauharnois No. 4, however, the master decided to try to correct the trim before arrival at Cornwall. At about 1115 the afterpeak was ballasted with 100 tonnes of water to correct the trim by the head. Calculations made using the vessel's stability data show that this amount of ballast would cause a change in trim aft of 26.8 cm. In consequence, the new trim would be 3.8 cm by the stern. For a vessel of the dimensions of the SUNNY BLOSSOM, however, transiting a shallow channel, it is possible that the fore part of the vessel was subject to the effect of squat. The squat has been calculated to have been about 90 cm. Under these circumstances, it is possible that steering the vessel was more difficult than it would have been in open sea, but this squat was not unusual for the SUNNY BLOSSOM at this location. Given the existing conditions of helm (20 degrees to port), engine (full ahead), and vessel position at the time the error was discovered, it is unlikely that the trim or the effect of squat contributed to the grounding. Pilotage Techniques During a watch at sea, the person having the conduct of a vessel should employ certain fundamental techniques to assure a safe passage. This is even more critical when a vessel is in restricted waters. When more than one person is involved in the conduct of a vessel, e.g. when a helmsman is at the wheel, an OOW is maintaining a record of the vessel's position and a pilot has the conduct of the vessel, these techniques must be mastered to avoid errors of communication, understanding and execution of orders. One of the practices widely adopted by pilots and OOWs is to have the helmsman repeat the order given--both on its receipt and upon its execution. The pilot or OOW then confirms, by repeating the order, that it has been carried out. This practice creates a closed circuit of repetition and confirmation of orders given by the pilot or OOW to the helmsman. Another practice is for the person having the conduct of the vessel to look at the rudder angle indicator after giving a helm order. In doing so, they can be assured that the order has been understood and carried out. This is of great importance when the vessel is in restricted waters or in areas where traffic is heavy. Neither the pilot nor the apprentice pilot was looking at the rudder angle indicator during the last alteration of course entering the Cornwall channel. Notwithstanding the differences of opinion on why the helm was put to port, all those on the bridge agreed that the vessel went aground as a result of the helm being put over to port instead of to starboard, and that this occurred at a critical time during the course alteration. Between the time that the helm was put to port, about 1154, and the movement of the vessel to port, some time elapsed.[5] It is estimated that the SUNNY BLOSSOM would have taken about 25 seconds to start its swing to port from the time that the initial helm order was given. At 8 knots, the distance covered would have been about 103 m. From the position at 1154, the 103 m covered on a course of 255(G) would have placed the vessel in an unrecoverable position, given that the rudder was at this time 20 degrees to port with the engine full ahead and a port swing started, and notwithstanding a current setting at 060(T) at this position.[6] Bridge resource management principles advocate that crew members share information to ensure as much as possible that all relevant factors are taken into account in the decision-making process; such principles are a catalyst for other officers to be assertive when faced with a perceived unsafe situation. In this occurrence, the master had drawn the OOW's attention to the fact that, even if the pilot had the conduct of the vessel, the OOW should take command of the ship in circumstances where safety was compromised. Notwithstanding this warning, the OOW was inhibited from asserting himself before the occurrence by at least three obstacles. These were: There was a pilot and an apprentice pilot in the wheel-house. The fact that the pilot did not contradict the orders of the apprentice pilot had the effect of an implicit endorsement. The combined weight of their authority was not conducive to a challenge by the OOW. The OOW was at the engine telegraph carrying out the pilots' orders and was plotting the vessel's position on the chart about every six minutes, when he was not required at the telegraph. Without the benefit of an electronic chart to continuously follow the vessel's progress in real time, it was extremely difficult, given his responsibilities at the telegraph, to evaluate the appropriateness of the apprentice pilot's orders. No information on the pilot's intention, such as wheel-over positions, was exchanged between the pilot and the bridge team. Because of this, it was impossible for the OOW to know with certainty the alter-course (wheel-over) position. With reference to this third point, an OOW must know the pilot's intentions for the intended voyage. The Canadian Code of Nautical Procedures and Practices, Operational Guidance for Officers in Charge of a Navigational Watch specifies that if the OOW is in any doubt as to the pilot's actions or intentions, he should seek clarification from the pilot; . . . . and take whatever action is necessary . . . .[7] Without an understanding of intentions, it is difficult to evaluate with certainty the appropriateness of the pilot's actions, or to doubt them. In October 1995, the Transportation Safety Board recommended that: The Department of Transport require that pilots, as part of their initial hand-over briefing: obtain the master's agreement to the intended passage plan; and invite the bridge team's support by having the officer of the watch plot and monitor the vessel's position at regular intervals and report the position to the pilot with respect to the agreed passage plan. Transport Canada indicated acceptance of the intent of the recommendation. Consultation with the pilotage authorities has taken place and the syllabus for bridge resource management training contains passage planning and simulated passage exercises. Work/Rest Schedule The time of day at which one sleeps has an effect on the quality of sleep. Nearly every function of the body, including sleep and wakefulness, is regulated following the day/night cycle known as circadian rhythm. Circadian rhythms are influenced by external stimuli, such as sunrise and sunset, but above all by the body's biological clock. Human performance is better if the subject sleeps at night and is awake during the day. People who are asleep at times when their biological clock tells them that they should be awake have difficulty sleeping, and the sleep they do get does not have the same restorative value.[8] Pilotage requires irregular and unforeseeable hours of work. These factors make pilots vulnerable to sleep debt. The GLPA controls pilot's assignments so that after every assignment a pilot benefits from a period of at least 14 hours before being reassigned. However, this does not mean that the period without assignments is a period of rest or sleep. The GLPA cannot control the quantity or quality of sleep its pilots receive. The pilot had more than 24 hours off between his previous assignment and the one on the SUNNY BLOSSOM; however, because the pilot had slept for only 3 hours in the 24 hours before the grounding, it is likely that he was tired at the time of the occurrence. The deterioration in performance due to fatigue manifests itself in several ways, inter alia: reaction time is slower and reasoning and judgement are less sure, there is a decrease in vigilance, a lack of appropriate reaction to difficulties, nonchalance, and an increased propensity to take risks.[9] The pilot was on the port side in the wheel-house and was looking forward. He had no knowledge of the actions of the helmsman or of the helm orders given by the apprentice pilot immediately before the occurrence. These facts would lead the Board to believe that he was not controlling the quality of the services rendered by the apprentice pilot. Such behaviour is compatible with performance reduced by fatigue. During the winter of 1998, most of the pilots of the GLPA, including the pilot of the SUNNY BLOSSOM, attended a three-hour seminar on sleep and hours worked. Notwithstanding this awareness session, and the fact that the pilot had been piloting since 0120, the pilot decided to continue piloting between Beauharnois and Cornwall. Research has shown that an individual, particularly an individual who is fatigued, does not correctly evaluate his state of wakefulness and performance.[10] Quality Control of Pilotage Services Having recourse to the services of an apprentice pilot, even an experienced apprentice pilot, was not a reason for the pilot to relax his vigilance. At all times, he was required to assure the quality of the service rendered by the apprentice pilot and the helmsman. In restricted waters, as this occurrence shows, continuous vigilance is necessary to validate the parameters of the operation. This can make the difference between a voyage without incident and one with undesired consequences. When informed that there would be no relief pilot before 1600, the pilot decided to continue between No. 4 Lock at Beauharnois and Cornwall. Leaving No. 4 Lock at Beauharnois the SUNNY BLOSSOM was trimmed 23 cm by the head, but after having ballasted the afterpeak with 100 tonnes of ballast, the vessel's trim would have been 3.8 cm by the stern. This was probably the vessel's trim immediately before the grounding. It is unlikely that the trim or the effect of squat contributed to the grounding. At a critical moment in the alteration of course to starboard, the helm was put 10 degrees to port and then 20 degrees to port. At the time of the occurrence, the apprentice pilot had the conduct of the vessel while the pilot was on the port side of the wheel-house. There was no efficient closed circuit of repetition and confirmation of helm orders between the person having the conduct of the vessel and the helmsman. At the time of the last alteration of course to enter the Cornwall channel, the apprentice pilot's attention was fixed on the vessel's foremast to detect the alteration. The OOW carried out the main engine telegraph orders as given to him by the pilots. He marked down the vessel's position on the chart about every six minutes, when his services were not required at the telegraph. Given his responsibilities at the telegraph and without the benefit of an electronic chart to continuously follow the vessel's progress in real time, it was extremely difficult for the OOW to evaluate the correctness of the apprentice pilot's orders. No information on the pilot's intentions, such as wheel-over positions, was exchanged between the pilot and the bridge team. As such, the OOW did not know with certainty the course alteration (wheel-over) position and so could not properly evaluate the pilot's actions. Neither the pilot nor the apprentice pilot looked at the rudder angle indicator to confirm that helm orders were being correctly executed while the vessel was leaving the main channel to enter the Cornwall channel. The quality of service provided by the apprentice pilot was not continually verified by the pilot. A little after the start of the vessel's head coming to port, the helm was put hard to starboard and the main engine to full astern.Findings When informed that there would be no relief pilot before 1600, the pilot decided to continue between No. 4 Lock at Beauharnois and Cornwall. Leaving No. 4 Lock at Beauharnois the SUNNY BLOSSOM was trimmed 23 cm by the head, but after having ballasted the afterpeak with 100 tonnes of ballast, the vessel's trim would have been 3.8 cm by the stern. This was probably the vessel's trim immediately before the grounding. It is unlikely that the trim or the effect of squat contributed to the grounding. At a critical moment in the alteration of course to starboard, the helm was put 10 degrees to port and then 20 degrees to port. At the time of the occurrence, the apprentice pilot had the conduct of the vessel while the pilot was on the port side of the wheel-house. There was no efficient closed circuit of repetition and confirmation of helm orders between the person having the conduct of the vessel and the helmsman. At the time of the last alteration of course to enter the Cornwall channel, the apprentice pilot's attention was fixed on the vessel's foremast to detect the alteration. The OOW carried out the main engine telegraph orders as given to him by the pilots. He marked down the vessel's position on the chart about every six minutes, when his services were not required at the telegraph. Given his responsibilities at the telegraph and without the benefit of an electronic chart to continuously follow the vessel's progress in real time, it was extremely difficult for the OOW to evaluate the correctness of the apprentice pilot's orders. No information on the pilot's intentions, such as wheel-over positions, was exchanged between the pilot and the bridge team. As such, the OOW did not know with certainty the course alteration (wheel-over) position and so could not properly evaluate the pilot's actions. Neither the pilot nor the apprentice pilot looked at the rudder angle indicator to confirm that helm orders were being correctly executed while the vessel was leaving the main channel to enter the Cornwall channel. The quality of service provided by the apprentice pilot was not continually verified by the pilot. A little after the start of the vessel's head coming to port, the helm was put hard to starboard and the main engine to full astern. The SUNNY BLOSSOM ran aground on the south bank of the Cornwall channel when, at a critical moment of an alteration of course to starboard, the helm was put to port. Factors contributing to the grounding were: the apprentice pilot did not confirm, by reference to the rudder angle indicator, that helm orders had been carried out, and there was no efficient closed circuit of repetition and confirmation of helm orders between the person having the conduct of the vessel and the helmsman; the pilot did not continually verify the quality of service provided by the apprentice pilot; and the multiple responsibilities of the OOW combined with his lack of information on the position at which the vessel was to change course inhibited him from intervening at the critical moment.Causes and Contributing Factors The SUNNY BLOSSOM ran aground on the south bank of the Cornwall channel when, at a critical moment of an alteration of course to starboard, the helm was put to port. Factors contributing to the grounding were: the apprentice pilot did not confirm, by reference to the rudder angle indicator, that helm orders had been carried out, and there was no efficient closed circuit of repetition and confirmation of helm orders between the person having the conduct of the vessel and the helmsman; the pilot did not continually verify the quality of service provided by the apprentice pilot; and the multiple responsibilities of the OOW combined with his lack of information on the position at which the vessel was to change course inhibited him from intervening at the critical moment.